Military Medical EthicsEthical DichotomiesCultural Pluralism
David A. Anderson, DDS, MDS
United States Uniformed Services Oath of Office
I do solemnly swear that I will support and defend the Constitution of the United States against all enemies, foreign or domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion, and that I will well and faithfully discharge the duties of the office on which I am about to enter. So help me God.
Objectives
To honor those in uniform that tend the war-woundedTo name the uniform services:
USAF, USA, USCG, USMC, USN, USPHS and NOAA
To contrast civilian and military medical ethical premises
Military Medical Ethics Short Course
Walter Reed Army Medical Center27-30 October 2009
http://www.wramc.amedd.army.mil/Support/chaplain/pages/mesc.aspx
Elspeth Cameron Richie, M.D., Ph.D
Decision Making Capacity
Confidentiality, Privilege & Truth Telling
Battlefield and Detainee Ethics
Ethical Issues & Humanitarian Missions
Roger A Miller, D.Min, M.Div, MABMH
History of Bioethics
Principles of Bioethics
Ethical Guidelines for End-of-Life
Robert M. Veatch, M.A., M.S., Ph.D.
Medical Ethics OverviewOrgan TransplantsHuman ExperimentationFutile CareAllocation of Scarce ResourcesVirtue Ethics
Carlos Gomez, Ph.D., M.D.
Palliative Care and Advanced Dementia
Catherine With, J.D., L.L.M.
Legal Guidelines for End-of-Life
Advanced Medical Directives
Complimentary and Alternative Medicine
Peter Weina, Ph.D., M.D.
Physician Assisted Suicide
Kim S. Meyer, MSN, ACNP-BC, CNRN
Ethical Considerations in TBI
Stacy Weina, FNP-BC
Ethical Concerns in Nursing
Medical Ethics
Beneficence
Nonmaleficence
Autonomy
Justice
Health Care EthicsHuman Dignity
Common Good
Subsidiarity
Solidarity
Justice
Ethics Consultations
Four “D” Matrix Data
Deliberation
Decision
Direction
Ethics Consultations
Clarify the consultation requestAssemble the relevant informationSynthesize the informationExplain the synthesisSupport the consultation process
Integrated Ethics
Identify an issueStudy the issueSelect a strategyUndertake a planEvaluate and adjustSustain and spread
Battlefield and Detainee Ethics
Battlefield Triage Categories
MinimalCommanders want the least injured returned to duty firstThe “good”= return to duty with minimal careDelayed treatment for more urgent categories
ImmediateAmputations, airway management, lacerations, shock
The “good”= stabilize to saveFirst priority for treatment
Battlefield Triage Categories
DelayedOut of danger after immediate treatment
The “good”= priority lest they get worseSecond priority for treatment
ExpectantComplicated case, prolonged condition, little hopeThe “good”= comfort onlyLast priority for treatmentShould this category exist today
Law of War
Complex SubjectProportionalityRules of EngagementTorture not allowed
Geneva Convention 1949
Wounded personsProtected personsReturn of medical and religious personsIdentification of medical and religious personnelTreatment of Prisoners of War
More than the Geneva Convention Now Needed
Haitian refugeesSelf mutilating behavior
Somali Patients in US hospitalsStealing from the staff
The Israeli experienceCaring for suicide bombers (who failed)Pregnant women concealing bombs at checkpoints
Targeting of ambulances in Iraq
Ambulances as bombs
Euthanasia on the Battlefield
Active vs. passive
Tactical vs. medicalReasons:
keep from exposing positionsavoid torture / painful deathkeep information from falling into enemy handsunit can save itselfretain medical personnel
Ethics of Combat Psychiatry
“To retain the fighting strength”Proximity, Immediacy, Expectancy, Simplicity (PIES)Stated goal is return to duty (not to minimize the long term consequences)Psychiatrist as “double agent”Challenge of distinguishing harm and benefit
Other Battlefield Ethical Issues
Using “experimental drugs” in battlefield setting
IND drugs, PB, anthrax
Medics in the field- does the Red Cross make them a target?
Research“go pills”
DetaineesStatus: Not POWs
Medical Care
Interrogations
Feeding tubes
Release Home
Ethical Issues in Humanitarian Missions
Official reasons for the mission
Do we win the minds and hearts of the people?
Medical Rules of Engagement (MROE)who and how to treatmay change with tactical situation
Ethical Issues in Humanitarian Missions
Public Health IssuesParochial Capacity BuildingSustainability of protocols, relationships, technology supportAdvance exploration of unintended consequences
Ethical Issues in Humanitarian Missions
Cascade of Care RecipientsUS SoldiersAlliesWounded enemyCivilians
Employed by USAcute vs. chronic careage
Ethical Issues in Humanitarian Missions
Geneva ConventionArmed conflict between sovereigntiesNot applicable to ethnic conflictsRed Cross is targeted
Medical clinic target for theft
Ethical Issues in Humanitarian Missions
Winners know that preparation is the key.Vigilant Security/ Egress PlanPTSD from RwandaPreparation for atrocitiesIs PIES appropriate?Stress inoculationProvider resilience training
On behalf of the President of the United States, the
Department of the Air Force, and a grateful nation, we
offer this flag for the faithful and dedicated service of……
God bless you and this family, and God bless the United
States of America.